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General NPI Number Information
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NPI Number | 1770031403
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Entity Type | Individual
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Provider Name | KELSI MADELYN KOCMOUD PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/12/2016
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Last Update Date | 09/17/2022
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Provider Practice Location Address
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Address Line | 13943 N 91ST AVE STE B101
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City | PEORIA
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State | AZ
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Zip | 85381-3688
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Country | US
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Telephone | 623-476-5390
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Fax |
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Provider Business Mailing Address
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Address Line | 5995 N 78TH ST UNIT 2008
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City | SCOTTSDALE
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State | AZ
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Zip | 85250-6123
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Country | US
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Telephone | 623-414-1246
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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